Daily Habits to Preserve Your Practice

Follow these simple dos and don’ts to keep your documentation game strong.

DO DOCUMENT: exam and findings; clinical decision-making; orders; consultations; diagnosis and disposition; communications; conversations; contemporaneously and with care

DON’T DOCUMENT: after you receive notice of a complaint; what your opinion is of patient intentions or motives; what you think about the other clinicians involved

Don’t fall prey to a forced diagnosis. You want to be as confident as possible in why you chose your diagnoses—and able to clearly articulate your reasoning, if asked.

During a busy day or after a long shift, patient transition or hand-off might be the last thing you want to spend a lot of time on. Before you move on to the next thing or head home, make sure you’ve been clear and comprehensive with the provider who is taking your patient. Give the full picture; assess the patient; document well; and be aware of outstanding tests.

Easier said than done, we know—but it’s not a foregone conclusion. In the midst of everything going on and the certain exhaustion they are feeling, clinicians can lose sight of how critical the simple act of being nice is. So, speak kindly; listen closely; check in with your patients, colleagues, and yourself; set expectations— then follow through; provide regular updates to caregivers; and don’t forget to smile.